EmailMe Form - Alabama Pathways PDR Enrollment Application

Alabama Pathways PDR Enrollment Application

At this time, only Enrollment Applications for individuals whose center is eligible to participate in Alabama Quality STARS will be processed and placed into the Alabama Pathways Professional Development Registry (PDR). If you have questions or need assistance with completing this application, contact us via e-mail at help@alabamapathways.org or by phone at (251)473-1060.

Please complete all requested fields. Fields marked with an asterisk (*) are required. It will delay the processing of your application if these fields are not marked.

There may also be supporting documentation required along with your Enrollment Application. We encourage you to submit documentation of your highest level of education so that we can accurately place you on an Alabama Pathways Professional Development Lattice Level; however, this documentation is not always required by Alabama Quality STARS. Refer to the Alabama Pathways PDR Enrollment and Documentation Requirements chart to determine what documentation is required at each STAR level.

Submit copies of your supporting documentation with your Enrollment Application. These documents will be kept on file with Alabama Pathways PDR and will not be returned. Please do not send original documents. If additional information and/or documentation is needed, you will be notified.

Identifying Information
First Name *
Middle Name *
Last Name *
Maiden Name
Please write N/A if this does not apply.
Date of Birth *
MM / DD / YYYY
Last FIVE (5) Digits of SS# *
Contact Information
Home Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
County of Residence *
Personal Email Address *
This is the e-mail address that Alabama Pathways PDR will use to correspond with you. If you receive an error regarding your email address when submitting this application, please contact us at 251-473-1060.
Primary Phone *
### - ### - ####
Provide the phone number that you want Alabama Pathways PDR to use should we need to contact you.
Cell Phone
### - ### - ####
Demographic Information
Gender *
Male
Female
Prefer Not To Answer
Ethnicity *
Race *
Primary Language *
The language in which a person speaks most proficiently.
Secondary Language
Other language(s) in which a person speaks proficiently.
Learning Language
The language in which a person prefers to learn.
Formal Education Information
Highest Level of Education *
Degree Name
Degree Name if Not Listed Above
Field of Study
Child Development
Early Childhood Education
Elementary Education
Early Care & Education
Other
Field of Study if Not Listed Above
College/University
Date Degree Awarded
MM / DD / YYYY
Do you have an Alabama Early Learning Guidelines Credential? *
Do you have an Child Development Associate Credential? *
CDA Expiration Date
MM / DD / YYYY
Have you completed training on the Program Administration Scale (PAS) assessment tool? *
Center Directors - Supporting documentation of this training is required at all STAR levels.
Have you completed training on the ITERS assessment tool? *
Center Directors - Supporting documentation of this training is required at all STAR levels.
Have you completed training on the ECERS assessment tool? *
Center Directors - Supporting documentation of this training is required at all STAR levels.
Current Employment Information
Center Type *
Center Name *
If your employer has multiple sites, please specify the site at which you work.
Center Physical Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Center's County
Work Phone *
### - ### - ####
Work Email
Current Position *
Other Position
Please complete if you indicated your current position as "other" in the previous question.
Employment Start Date *
MM / DD / YYYY
Are you Part-Time (less than 20 hours per week) or Full Time *
Ages of children you're working with 20 or more hours per week. *
Supporting Documentation for Pathways Application
Education Documentation

If you are submitting a college degree diploma, YOU MUST SUBMIT THE CORRESPONDING TRANSCRIPT IN ORDER FOR THAT DEGREE TO APPLY TOWARD YOUR LATTICE LEVEL.

Documentation of the highest level of education is required for teaching staff of centers applying for STAR levels Two, Three, Four and Five.

(Supported document types include pdf, jpg, png, or gif. The size limitation is 10MB per file. There are also several smartphone scanner apps that will convert photos to pdf format. We recommend Genius Scan, available on the Apple iTunes and Google Play Stores. If you don't have a scanner, a cell phone photo of the document will do!)
Upload High School Diploma/GED
(Supported document types include pdf, jpg, png, or gif.)
Upload Alabama Early Learning Guidelines Credential
(Supported document types include pdf, jpg, png, or gif.)
Upload CDA
(Supported document types include pdf, jpg, png, or gif.)
Upload Highest Degree Diploma
Please scan multiple Diplomas into ONE file. (Supported document types include pdf, jpg, png, or gif.)
Upload College Transcipt
Please scan all Transcripts into ONE file. (Supported document types include pdf, jpg, png, or gif.)
Professional Development Documentation (Training)

Training certificates verifying 4 clock hours of training above the Minimum Standards required annual training from an outside source are required at STAR levels Three, Four and Five.

(Supported document types include pdf, jpg, png. The size limitation is 10MB per file. There are also several smartphone scanner apps that will convert photos to pdf format. We recommend Genius Scan, available on the Apple iTunes and Google Play Stores. If you don't have a scanner, a cell phone photo of the document will do!)
Upload Training Transcripts or Certificates
Please scan Multiple Training Attendance Verification Certificates documents into ONE file in DATE ORDER. (supported file type include pdf, jpg or png,)
Additional Documentation

Please submit any PAS, ITERS and ECERS Certificates.

Documentation of this training is required for Center Directors at all STAR levels.

(Supported document types include pdf, jpg, or png. The size limitation is 10MB per file. There are also several smartphone scanner apps that will convert photos to pdf format. We recommend Genius Scan, available on the Apple iTunes and Google Play Stores. If you don't have a scanner, a cell phone photo of the document will do!)
Upload PAS Certificate
Upload ITERS-R Certificate
Upload ECERS-R Certificate
Signature and Date
I, the undersigned, have read and agree to all statements indicated in this application. I hereby agree that the information provided in this application form is complete, accurate, and will be entered in the Alabama Pathways Professional Development Registry. I understand that I am responsible for information included in this application and agree to update my information with Alabama Pathways Professional Development Registry when applicable.

I understand that the information in my profile will be used for the following purposes:

1. Your information will be shared with Alabama Quality STARS and used for center STAR level determination.

2. Your information will be used by Alabama Pathways Professional Development Registry for Lattice Level placement determination, recognizing individual’s education attainments (such as attainment of a Child Development Associate or Bachelor’s degree).

3. Your information will be used to compile, analyze, and publish group data reports.

Data compiled from the Alabama Pathways Professional Development Registry may be released to aid community and state planning to increase the quality and services of the early care and education community. Your name will not be released to advertisers. Information that could affect the safety and security of an individual (i.e. social security numbers, birth dates and personal addresses) will not be released to any individual or agency other than the Alabama Department of Human Resources and Alabama Quality STARS.
Name *
First Last
Date *
MM / DD / YYYY
If you have questions or need assistance completing this form, please contact Alabama Pathways Professional Development Registry at:
E-mail Address- help@alabamapathways.org
Phone Number - 251-473-1060
Mailing Address - 3100 Cottage Hill Road; Building 4, Suite 400; Mobile, AL 36606

Identifying Information

Contact Information

Demographic Information

Formal Education Information

Current Employment Information

Supporting Documentation for Pathways Application

Signature and Date

If you have questions or need assistance completing this form, please contact Alabama Pathways Professional Development Registry at: